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Medics:

The responsibility of the Medic is to evaluate the condition of their patient, provide the appropriate medical care while at the emergency scene and during transport to the medical facility in accordance to NYS and regional BLS and ALS protocols, transfer the patient to the care of medical facility staff, and to accurately document the care they provided at completion of call. Medics must be a NYS certified Emergency Medical Technician – Basic or Paramedic and complete appropriate training.

EMT-Basic:

Emergency Medical Technicians-Basic (EMT-B) respond to emergency calls to provide efficient and immediate care to the critically ill and injured, and to transport the patient to a medical facility in accordance to BLS protocol.

17. Additional Information:

18. Certification:

I hereby state that all of the above questions have been answered truthfully and without gross omission. I authorize PVEA to check my references and/or all of the above with proper law enforcement agency. I also understand that willful falsification or omission from this application will be cause for rejection or dismissal. It is further understood that this application will be handled in accordance with the Civil Rights Act of 1964 and no discrimination will occur because of age,
sex, religion, race, gender, sexual orientation, national origin or any other protected classification.

19. Privacy Notification:

Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor?*

Yes

No

If you answered yes please explain below with dates:*

APPLICANT’S AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I, the applicant signing this form, do hereby authorize a review and full disclosure of records concerning myself to PVEA, the Monroe County Sheriff’s Office and designated persons working on their behalf, whether the information be of public, private, or confidential nature; and I release them from any liability and responsibility from doing so.

The intent of this authorization is to give my consent for full and complete disclosure of records of all licensing agencies, educational institutions, and law enforcement agencies.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release of authorization will be considered in determining my suitability for membership / employment of PVEA. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release the PVEA, and the Monroe County Sheriff’s Office from any and all liability which may be incurred as a result of collecting such information.

A PHOTOCOPY OF THIS RELEASE WILL BE AS VALID AS AN ORIGINAL THEREOF, EVEN THOUGH THE SAID PHOTOCOPY
DOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.

I have read and fully understand the contents of this “Authorization for Release of Personal Information.”

Applicant Signature:*

(Sign with finger or mouse pointer)

Applicant Signature Date:*

Please attach a Copy of driver’s license and other certifications with this completed application.*